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Hard labour

Just how traumatic is childbirth? We all know that having a baby hurts - but that's soon forgotten, surely? Kate Hilpern on why, for some women, it is an experience that leaves deep psychological scars

"Being raped" is how Liz Darke describes giving birth to her daughter. "I had no control," she says, "over what people were doing to my body, despite being fully alert and explaining again and again the kind of treatment that I did and didn't want. I felt I might as well have been a piece of meat." During the 18 months following her labour, Liz has experienced periods of feeling completely detached from other people, including her baby, and has suffered flashbacks, recurrent dreams of the event, and excessive sweating and anxiety. All symptoms of post traumatic stress disorder (PTSD).

And Liz is not alone. As many as one in 20 mothers suffer PTSD after giving birth, according to a report published this week by Stephen Joseph, a psychologist at Warwick University, with Dawn Bailham, a child psychologist at Northampton General Hospital. For such women, additional symptoms include having little confidence in their bodies, struggling with breastfeeding, parenting problems, a feeling of failure and avoidance of sex.

"PTSD was first identified in soldiers during the Vietnam war, and previously known as 'shell shock' in the first world war," says Joseph. "More recently, it was accepted that people suffering from accidents or disasters could suffer the same symptoms. We now have evidence that PTSD may be suffered as a result of a traumatic birth experience." For women affected by PTSD, the birth experience equates to psychological or physical torture, with emergency caesareans and difficult labours being common causes. Very few cases of PTSD are recorded among women who have had home births; in fact, the disorder tends to occur more with hi-tech births, according to Jean Robinson, honorary research officer at the Association for Improvements in the Maternity Services (Aims).

"It is no coincidence that cases of PTSD rose at the same time as the massive increase in induced labours," she argues. "Nor is it a coincidence that cases have remained common in births when there are other interventions like revving up the uterus with drugs to speed labour up." She suggests that even "normal" births can lead to PTSD, as women are often left feeling helpless at one of the most important events in their lives. One of Joseph's recommendations is that services need reform precisely to address this issue of helplessness.

Perhaps not surprisingly, PTSD is often misdiagnosed as post-natal depression by health professionals. But, explains childbirth expert and author Sheila Kitzinger, "PTSD is distinct from postnatal depression and far more damaging. PTSD is essentially a state of panic - and while it can include depression, that is not its primary state. Women have nightmares and flashbacks, often feeling unable to go near a hospital or look at pregnant woman because it is a reminder of their trauma."

PTSD is distinct, she adds, since initially you are numb, just relieved it's over. Only later do the floodgates open - often after several months or even after the baby's first birthday. "PTSD is also far more complicated than post-natal depression because it is a direct result of a woman's trauma," says Kitzinger, "yet she may feel bound to be grateful to the very people who violated her and caused that trauma." The repercussions of misdiagnosis are grave, she argues, not least because women are commonly prescribed anti-depressants - "which makes them even less able to cope".

The effects of PTSD can be severe - one example being tokophobia, an intense anxiety or fear of death, which leads to some women dreading or avoiding childbirth despite wanting a baby. Kristina Hofberg, a psychiatrist at the mother-and-baby unit at the Queen Elizabeth Psychiatric Hospital in Birmingham, explains: "While primary tokophobia occurs in women pre-dating pregnancy, the secondary form can occur after a traumatic or distressing delivery."

Other women experience problems in the relationship with their child, and their partner, says Robinson of Aims. "The rate of marriage break-up is high because the woman's personality appears to her partner to have changed. We hear of husbands saying, 'This is not the wife I had before.'" Suicide is now the largest single cause of maternal death, adds Robinson, who believes that many of the cases are due to PTSD. And, suggests Dr Manda Holmshaw, clinical director of Moving Minds Psychological Management and Rehabilitation, there is also a grow ing number of fathers who suffer from PTSD as a result of childbirth. "Being present can be very disturbing, for reasons including the amount of blood, fear of the death of the partner and/or child, and being asked to leave the room without explanation for long periods. I believe fathers can be affected to an equal degree."

But Joseph is the first to admit that his report has its sceptics. "Many point to the definition of PTSD as 'a normal reaction to an abnormal situation' and state that childbirth is not abnormal. In fact, there is quite a lot of controversy over what constitutes an abnormal situation, as well as what constitutes trauma. In spite of these arguments, there is clear evidence that some women have such awful experiences of childbirth that they suffer the same symptoms - flashbacks, anxiety and so on - as anyone suffering from PTSD."

Other critics of Joseph's findings stress that many women experience childbirth in a negative way, yet do not suffer from PTSD. His response is that some are more vulnerable than others - those who have experienced abuse in their past, or who have stressful lives, are more susceptible. "But we have also seen PTSD in strong, capable, confident women, so there is no blueprint for who may suffer," says Robinson. "It seems to me that nobody really seems to know why some people are susceptible to PTSD while others seem resistant."

Most experts do agree, however, that the sooner people are able to talk about their experiences, and start processing them psychologically, the better their chances of early recovery and long-term mental health. And research shows that it is normal and healthy to ruminate extensively on the birth experience - whether good, bad or mediocre. "People are now routinely screened for post-natal depression and I would like to see this screening broadened to include aspects of PTSD," remarks Joseph.

Robinson highlights another area for reform. "Almost inevitably, the story of a women suffering from PTSD is critical of those that cared for her. There is substantial sociological research that shows health professionals do not want to hear these stories - unless this changes, women will continue to be given the message that what they are going through is unnecessary and irrational."

For Laura Matthews, the simple acknowledgement that her childbirth was a traumatic experience assisted in her recovery. "I was diagnosed with PTSD 11 months after the birth of my child. I had experienced a very long labour, with very unsympathetic and incompetent staff who misused the equipment and offered no pain relief. I was shouted at, and the man who stitched me up asked my husband if he'd like to see his brilliant handiwork. Nobody washed my baby and so I had to take him home covered in blood.

"I was severely affected by these events," she now feels. "Initially, I felt shocked and that I was a failure. Over time, it was as though a colour video would go through my head of the events. I couldn't switch it off." For severe sufferers, PTSD can require extensive psychotherapy or drug treatment. But for many, Matthews included, just a few session of counselling is all that is needed. The simple acknowledgement that these women had a terrible experience, which wasn't their fault, can make a huge difference.

"Eventually, I approached my doctor who immediately diagnosed me with PTSD and referred me for help," says Matthews. "With her words alone, I felt like a huge weight lifted off my shoulders."'

About this article

Hard labour

This article appeared on p14 of the G2 section of the Guardian
on Tuesday 27 May 2003.
It was published on
the Guardian website
at 11.20 EDT on Wednesday 28 May 2003.
It was last modified at 11.20 EST on Thursday 3 November 2005.
It was first published at 11.20 EST on Thursday 3 November 2005.